Med. J. Cairo Univ., Vol. 62, No. 2, June : 401-407, 1994

Laparoscopic Management of Idiopathic Varicocele

EZZ ELDIN KORASH1,M.D.

The Department of General Surgery, Hadi cfih Kuwait

Abstract

Twenty patients with idiopathic varicoceles were managed by

laparoscopic endoclipping of the testicular vein on outpatient basis. In

three patients the varicoceles were bilateral. Clinical as well as pre and

postoperative Doppler Ultrasound confirmed the complete cure of the

varicocele. Laparoscopy proved to be of special value in the management

of bilateral varicoceles and the clipping of the unusually branching

testicular vein. A manoeuvre of clipping the testicular vein while the

varicocele is firmly squeezed, was used. It helps to distend the vein under

vision decongesting the testis

circulation.

and L encouraging venous collateral

Introduction

THE ADVENT of laparoscopic surgery

has opened new approaches to well esta-

blished methods of surgical treatment.

Among the myriad procedures already

available for treating a varicocele, laparo-

scopic management stands as the most up-

to-date. The present report presents our

initial clinical experience with laparoscop-

ic testicular vein ligation for varicocele.

The role of pre-, intra-and post-operative

doppler ultrasound is discussed.

The procedure is done on outpatient

basis and the patients are followed-up

with clinical examination and doppler ul-

trasound one month after the operation.

Materials and Methods

Three ports were used for performing

laparoscopic clipping of the testicular vein;

an ll.OOmm umbilical port for the tele-

scope, 5Smm port between the umbilicus

and the left anterior superior iliac spine

and a third 11.00 m.m. port between the

umbilicus and the symphysis pubis. In bi-

lateral cases, an additional 5.5 mm port be-

tween the umbilicus and the right anterior

superior iliac spine is used.

401

. .

402 Ezz Eldin Korashi

The left testicular vein is easily identi-

fied as it emerges from the internal ingui-

nal ring looping of the vas deferens and

gentle traction on the spermatic cord mov-

ing the vein are of additional help the pa-

rietal peritoneum over the vein is incised

and the vein is dissected free of the testicu-

lar artery. A doppler flow probe was placed

over the ipsilateral neck of the scrotum and

the testicular artery pulsations are auscul-

tated. Inira-abdominally, the presumed tes-

ticular artery is temporarily occluded with

an atraumatic grasper and disappearance of

the auscultated arterial signals at the scro-

tum denotes that such temporarily occluded

structure is the testicular artery which is

preserved. The vein is doubly clipped with

tetanium ciips, after squeezing the varico-

cele at the neck of the scrotum so that the

engorged vein is clipped

The clinical material of the present

work involved 20 patients with varico-

celes. In twelve patients, the main presen-

tation was infertility whereas the remaining

eight unmarried patients presented with

dragging pain. Three among the latter pa-

tients were harboring bilateral varicocele.

All patients were subjected to thorough

clinical examination and doppler ultra-

sound using eight mhz transducer with the

probe applied to the neck of the scrotum.

Whether there is reflux of blood flow in

the auscultated venous signals, the follow-

ing manouvre is used:

a) The patient performs a Valsalva Ma-

nouvre raising the venous pressure in the

testicular vein causing reversal of blood

flow (Reflux) in patients with incompe-

tence of the valvular system. In normal

vein, no such phenomenon is recorded.

b) After relaxing the Valsalva Manouv-

re, the blood pooled in the pampiniform

plexus will return by a centripetal efflux

which is clearly accentuated in patients

with varicoceles.

Results

The median age of the patients present-

ing with infertility was 29 years while the

Table (1): The Clinical Grading And Venous Reflux in The Studied Patients.

Presentaion Infertility Pain or Venous

(N = 12) Distension (N = 8)

Grade I II III I II III

No. of Patients (%) 5 (41.6) 3 (25) 4 (33.3) - 5 (62.5) 3 (37.5)

Venous Reflux Positive Positive Positive - Negative Positive

Laparoscopic Management of Varicocele 403

median age of unmarried adolescent pa-

tients was 18 years. The clinical grading

of varicoceles into grades I, II, and III was

adopted according to Uehling 2. Pre-

operative venous reflux was detected by

doppler ultrasound in 15 patients; 75%,

(Table 1). The testicular artery could not

be identified in three patients. In three pa-

tients the main trunk of the left testicular

vein was short (21 cm.) branching imme-

diately above the internal ring into two

divisions necessitating clipping of both

divisions (Fig. 1). One left testicular vein

has been visualized in 18 patients (Fig.

2), whereas in 2 patients two veins could

be seen (Fig. 3).

Follow-up after one month by clinical

and doppler ultrasound examination re-

vealed absence of clinical recurrence and

disappearance of pre-operative venous sig-

nals at the neck of the scrotum.

Discussion

A varicocele first develops in early ad-

olescence [3], rarely in the pediatric age

group [4]. The progressive adverse ef-

fects on testicular function and growth ex-

plain why in adults normal fertility re-

turns following varicocele ligation in only

20 to 50% of patients [S]. Therefore, we

have included adolescent patients with va-

ricoceles in our clinical material for proph-

ylactic varicocele ligation as proposed by

other workers [q.

Among the various modalities of treat-

ment of varicoceles, most authorities adopt

either high ligation or embolisatidn of the

left testicular vein [7, 81. The latter ap-

proach did not gain wide acceptance due to

the high rate of recurrence [9] and compli-

cations [lo]. In a comparative study be-

tween high ligation and embolisation, the

later procedure yielded inferior results in

seminograms [8].

Several reports concluded that high ret-

roperitoneal ligation of the left testicular

vein exhibits certain merits; the improve-

ment in sperm quality, the absence of tes-

ticular atrophy and the low recurrence and

morbidity [3, 51.

Laparoscopic ligation of the left testic-

ular vein with or without preservation of

the testicular artery has been increasingly

used in recent years [l, 11, 12, 13, 14).

In Addition to the low morbidity of la-

paroscopic surgery, an excellent view of

the testicular vein displaying variations in

number and branches, is visualized [ll.

Anatomical variations in the number and

branches of the left testicular vein are not

uncommon [15, 161. Bifurcation of the

left testicular vein into medial and lateral

branches at the lumbar level was a constant

finding in the study of Wishahi [15] but

occurred in 45% of cases of Sofikitis et al

[16]. It occurred in 3 of our patients;

15%. The presence of more than one left

testicular vein; up to 5 in the lumbar re-

gion is previously reported [lq. The pres-

ence of such variations constitutes a strong

argument in favor of the laparoscopic ap-

404 Ezz Eldin Korashi.

Fig. (1): Early

ring.

Ill .enching of the left testicular vein into IWO divisions just ahn~ te the ink xnal

FIN. (2): One large Icl’t tesllcular win rc;rJy lor cllpping

Fig. (3): Two testicular veins (one has been dissected) emerging from the internal ring.

Laparoscopic Management of Varicocele 405

preach as the excellent visualization of the

anatomy precludes ligation of one of the

branches in mistake of the testicular vein

or missing another testicular vein; both

are causes of recurrence of the varicocele

after conventional retroperitoneal high li-

gations [9, 121.

Identification of the testicular artery by

intra-operative doppler ultrasound in the

present wor.k was also used by alberg et al

‘[l]. Flushing the testicular vein-artery

complex with papaverine solution during

laparoscopy was used by Clayman et al

[13] to dilate the a&y helping its iden-

tification and preservation. However, Kass

and Marco] [3] pertain that it is unneces-

sary to spare the artery as this will miss

ligation of collateral veins intimately as-

sociated with the artery which may later

dilate causing recurrence. In addition,

mass retroperitoneal ligation did not lead

to testicular atrophy in several studies

[17, 181 although we failed to identify

the artery in 3 patients, no recurrence oc-

curred in the one month follow-up period

whether the artery was preserved or not.

In the present study, as well as in oth-

er studies, doppler ultrasound has been

used as an aid to the clinical diagnosis of

varicocele and to verify whether venous

reflux is present or not (191. The disap-

pearance of the venous signals after lapar-

oscopic ligation in the present study is

considered a more accurate parameter for

success of venous ligation than clinical

judgment alone. The persistence of post-

operative venous xeflux with centrifugal

flow denotes missing of significant venous

tributaries with failure of complete venous

interruption; a situation which did not oc-

cur in our study during the follow-up peri-

od.

Laparoscopic ligation proved to be of

definite value in the treatment of bilateral

varicocele [l]. The condition occurred in

three of our patients (15%) and in 30% of

patients in other reports [3]. The manoever

of clipping the testicular vein while the va-

ricocele is firmly squeezed at the neck of

the scrotum helped us to identify the vein

by the venous distention. The manoever

helps also to decongest the testis encourag-

ing venous collateral circulation.

In conclusion, laparoscopic clipping of

the testicular vein is feasible on outpatient

basis. Excellent vision allows identifica-

tion of the vein and its anatomical varia-

tions as well as preservation of the testicu-

lar artery. Intra-operative doppler

ultrasound allowed identification, hence

preservation of the artery and its post-

operative use allowed objective assessment

in the follow-up period.

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